Reading Assignment in Potter, P., Perry, A., Stockert, P., & Hall, A. (2013).
Fundamentals of nursing (8th ed.). St. Louis, MO: Elsevier Mosby.
Nursing Assessment (Chapter 16)
Nursing Diagnosis (Chapter 17)
Planning for Nursing Care (Chapter 18)
Implementing Nursing Care (Chapter 19)
Evaluation (Chapter 20)
Documentation and Informatics (Chapter 26, pages 357-358)
Patient:
Patricia Newman, Medical-Surgical Floor, Room
406 Objectives:
Assess the health care needs of two patients.
Develop nursing diagnoses from available data.
Identify priorities of nursing care for two patients.
Develop goals and outcome statements.
Discuss factors to consider in choosing nursing interventions.
Exercise 1
Writing
This exercise will take approximately 30 minutes to complete.
1. A nurse is preparing to start her shift on a medical-surgical unit. Which of the
following factors concerning the change-of-shift report (hand-off report) will
be most important for the nurse to consider? (Hint: See pages 357-358 in
your textbook.)
a. Next anticipated dressing change
b. Patient's personality
c. Patient's family support
d. Off-going nurse's opinion about the patient's family background
Ans: A
2. Indicate whether the following statement is true or false. (p. 68)
Physiologic diagnoses have a higher priority than psychologic diagnoses.
Ans: False
, VCE 1: Lesson 3: Critical Thinking in Nursing Practice
3. Indicate whether the following statement is true or false. (p. 1316)
The Kardex provides a filing system for recording the physician's orders.
Ans: False
4. The statement that outlines the desired change in the patient's condition
or behavior is termed the GOAL . (Hint: See page 238 in your
textbook.)
Ans: Goal______
5. You are assigned to provide care to a patient who has recently had
abdominal surgery. When you are updating the nursing care plan, which
of the following patient outcomes would be appropriate to include? Select
all that apply.
a. The nurse will observe the patient's understanding of use of
the incentive spirometer.
b. The patient will demonstrate an increased level of comfort.
c. The patient will initiate turning and deep breathing within
2 hours.
d. The patient will be more comfortable.
e. The patient will report lessened pain using the pain scale within
3 hours.
Ans: C & E
6. A review of the care planned for a patient during a given shift reveals the
interventions listed below. Which of these interventions is classified as
an independent nursing intervention? Select all that apply.
a. Anchor an indwelling Foley catheter.
b. Discontinue IV.
c. Refer the patient for home health care.
d. Review complications to report after discharge.
e. Record intake and output.
Ans: A, D & E _
7. The nurse is assisting a newly graduated nurse in completing a care plan.
Which of the nursing interventions planned by the graduate and listed
below indicate the need for further instruction? Select all that apply.
a. Push fluids.
b. Monitor blood pressure.